GAP COVER

BASE

Life can be unpredictable, and so can your health.

This Gap Cover option is based on real benefits that offer real cover when it matters most, because when you become liable to pay doctors’ and specialists’ bills that your medical aid doesn’t cover in full, we’ve got the basics covered.

WE COVER

You and your spouse on one policy, even if you belong to different medical aids or medical aid options, including all dependants registered on your or your spouse’s medical aid option.

Each insured person to an Overall Policy Limit (OPL) of R 157 000 per person per year.

This is not a medical aid and the cover is not the same as that of a medical aid. This policy is not a substitute for medical aid membership.

MONTHLY PREMIUMS

ENTRY AGES

MONTHLY PREMIUM

BASE SINGLE

R 199,00

BASE FAMILY

R 230,00

BASE 65+

R 387,00

GAP BENEFIT

WE COVER

The gap that exists between what your healthcare providers charge and the rate your medical aid pays for medical procedures performed in hospital, a day clinic or your doctor’s or specialist’s private room when a portion of your healthcare providers’ accounts are paid from your hospital or risk benefit, and not from your day-to-day benefit or medical savings account.

CASUALTY BENEFIT

WE COVER

A casualty event at any registered medical facility when you require immediate medical treatment due to an accident.

Your healthcare providers’ accounts related to:

Doctors’ and specialists’ consultations;

Basic and specialised radiology;

Pathology;

Consumable items such as surgical gloves and bandages;

Medication administered or provided during your casualty event;

External medical items required as a result of your casualty event provided at the registered medical facility, such as a neck brace;

Return visits to the registered medical facility, when follow-up treatment is required as a result of your initial casualty event related to an accident; and

Upfront casualty co-payments or facility fees.

Your child under the age of 5, when they become ill and need after-hours medical treatment at a registered casualty facility.

You will be refunded for the cost of your casualty event when you become liable to pay your healthcare providers’ accounts out of your own pocket, or when your medical aid pays your healthcare providers’ accounts from your medical savings account, limited to R7 000 per policy per year.

TRAUMA COUNSELLING BENEFIT

WE COVER

The cost of your trauma counselling consultation fees when you:

have witnessed, or are directly affected by an act of physical violence or an accident;

have received word of a loved one’s, or your own diagnosis of a dread disease; or

mourn the death of a loved one.

You will be refunded for the cost of your registered counsellor’s, clinical psychologist’s or psychiatrist’s consultation fees when you become liable to pay your healthcare providers’ accounts out of your own pocket, or when your medical aid pays your healthcare providers’ accounts from your medical savings account, limited to R6 000 per policy per year.

ONCOLOGY CARE BENEFIT

CANCER DIAGNOSIS BENEFIT (Not subject to the OPL)

WE COVER

A once-off benefit amount of R5 000 when you are diagnosed with cancer for the very first time before you reach the age of 65, subject to specific qualifying criteria as explained under our benefit exclusions.

ADDITIONAL BENEFIT

ACCIDENTAL DISABILITY AND DEATH BENEFIT (Not subject to the OPL)

WE COVER

You and your spouse in the event of your total and permanent disability or death due to an accident, limited to 1 eventper person per year to a benefit amount of R6 000.

OUR 20% BENEFIT RULE

Should you claim from our GAP BENEFIT after the General Waiting Period but within the first 10 months of cover for the below listed medical events, your related healthcare providers’ accounts will be covered at 20% of the approved medical expense shortfall amount:

Adenoidectomy, Tonsillectomy, Myringotomy/Grommets, Cardiovascular procedures, Cataract removal, Dentistry, Hernia repairs, Hysterectomy (if required due to cancer that is diagnosed after the General Waiting Period applicable to your policy, your claim will be covered in full), Joint replacements, MRI, CT and PET scans, Nasal and sinus surgery, Pregnancy and childbirth, Spinal procedures and Scopes.

If your medical event is due to a pre-existing medical condition, your claim will be subject to the Pre-Existing Condition Waiting Period applicable to your policy. If this waiting period does not apply your claim will be covered at 20% as specified above.

Claims for accidental events that occur after your cover start date will be covered in full from the first day of cover.

During this period, cover does not apply unless you are claiming for an accidental event that occurs after your cover start date.

12 MONTH PRE-EXISTING CONDITION WAITING PERIOD

During this period, cover does not apply for an investigation, treatment, procedure or surgery relating to any illness or condition that you have been diagnosed with and/or received advice or treatment for 12 months before your cover start date.

GAP COVER BENEFIT EXCLUSIONS

OUR GAP BENEFIT DOES NOT COVER

Line items on your healthcare providers’ accounts;

paid in full from your hospital or risk benefit, or as a concession or ex-gratia payment.

not partially paid from your hospital or risk benefit.

partially paid or paid in full from your day-to-day benefit or medical savingsaccount.

while you are in your medical aid self-payment gap.

for a private upfront fee that you must pay and cannot claim back from yourmedical aid.

Medical procedures subject to a rand amount limit, where you become liable to pay a portion of, or the full amount of your medical procedure because the benefit limit does not cover the full amount of your medical procedure, or where the benefit limit has been reached.

Hospital accounts including, but not limited to theatre and ward fees.

OUR CASUALTY BENEFIT DOES NOT COVER

Healthcare providers’ accounts;

for a casualty event not due to an accident, or not due to illness of your child under the age of 5.

for a casualty event due to an accident, but medical treatment was not provided immediately.

for medication not administered or provided during your casualty event or your related follow-up consultation, as well as prescription and take-home medication.

for a return visit for follow-up treatment not related to an accident.

for external medical items not received during your initial casualty event.

for a casualty event where treatment due to illness was provided to your child under the age of 5 at a medical facility other than a registered casualty facility.

for a casualty event where treatment due to illness was provided to your child under the age of 5 at a registered casualty facility, but medical treatment was not provided after-hours. After-hours is Mondays to Fridays between 18:00pm and 07:00am and Saturdays, Sundays and public holidays.

for a casualty event where medical treatment due to illness was provided to your child aged 5 and older.

paid in full from your risk benefit.

OUR TRAUMA COUNSELLING BENEFIT DOES NOT COVER

Healthcare providers’ accounts;

if you have not witnessed or are not directly affected by an act of physical violence or an accident.

if you are not affected by a loved one’s diagnosis of a dread disease or death, or by your own diagnosis of a dread disease.

paid in full from your risk benefit.

if your healthcare provider is not registered with a recognised South African regulatory body.

ONCOLOGY CARE BENEFIT

OUR CANCER DIAGNOSIS BENEFIT DOES NOT COVER

A cancer diagnosis;

that is not the first diagnosis made in your lifetime.

made before the first day your cover starts or during a GENERAL WAITING PERIOD.

for cancers of the skin, unless the cancer diagnosis is for cancerous moles that have invaded surrounding or underlying tissue.

where cancerous cells have not invaded surrounding or underlying tissue.

for Stage 1 breast or prostate cancer.

made after you have reached the age of 65.

ADDITIONAL BENEFIT

OUR ACCIDENTAL DISABILITY AND DEATH BENEFIT DOES NOT COVER

Events;

where total and permanent disability or death is not due to an accident.

that exceed one claimable event per qualifying person in a benefit year.

Nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission.

Events where the actual damage is covered by legislation, such as contractual liability and consequential loss.

Discounts directly negotiated with your healthcare provider where full reimbursement of the claim will result in enrichment.

Non-disclosure of material information that is likely to affect the assessment or acceptance of risk.

Dual insurance where cover is provided by more than one gap cover policy through different insurers, or the same insurer.